Reinstatement Request Form

Date: March 14, 2010

Executive Director
c/o Membership Service Center
District of Columbia Bar
1101 K Street NW
Suite 200
Washington, DC 20005

Dear Executive Director:

I hereby request reinstatement as an

Active,
Inactive, or
Judicial

member of the D.C. Bar.

Included with this letter is my payment of $ which I understand is the amount owed to the Bar for all unpaid dues, late fees and reinstatement fees, if applicable.

I hereby certify that I am not suspended, temporarily suspended, or disbarred by any disciplinary authority and that there are no complaints or charges against me pending before any disciplinary authority.

Signature

________________________________

Print Name

Bar Number

Current Business Address

Current Home Address

Mailing Preference (where mail should be sent)

Business Home

Daytime Phone

E-mail

Payment Method

Check Credit Card

Charge my:	VISA MC AMEX
Account no.:
Expiration date:
Name on Card:
Signature:
	Print and fax this form to 202-942-9752.

Check no.:	Enclosed

To verify the cost to reinstate your membership, contact the D.C. Bar Membership Service Center at 202-626-3475.